Provider Demographics
NPI:1740480565
Name:NGUYEN, LONG BAO (DO)
Entity type:Individual
Prefix:
First Name:LONG
Middle Name:BAO
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1670 MCKENDREE CHURCH RD
Mailing Address - Street 2:#800
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4107
Mailing Address - Country:US
Mailing Address - Phone:770-557-8788
Mailing Address - Fax:
Practice Address - Street 1:1670 MCKENDREE CHURCH RD
Practice Address - Street 2:#800
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4107
Practice Address - Country:US
Practice Address - Phone:770-557-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63507207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I108564Medicare PIN